“Doctor, can I record this conversation?”

It’s happened to me a couple of times already. But the question in the title of this post was never asked. Rather I was informed later on that my conversation with a patient or family was recorded without my knowledge. Smart phones have made it all too easy for patients to secretly record conversations with their healthcare providers. Simply hit a button,  lay it innocently down by your side in the office or hospital, and patients get an instant video or audio capture of a conversation with their physician.  When my medical team and fellow physicians found out about the unauthorized recording of our conversation, the news was met with a combination and anger and disgust.

That reaction, it seems,  is typical of what most physicians would feel in the same situation. Why would a physician be upset about a patient secretly recording a conversation with them?

Well, simple, really. Most physicians are in chronic fear that the next person to hear/view that recording will be a malpractice lawyer, dissecting it,  consonant by consonant,  probing for potentially actionable material. The recording, in the physicians mind, changes the nature of the physician-patient relationship. It makes the patient a potential adversary, it makes the doctor feel as if they are in front of a jury and can not speak frankly, it makes them feel as if they are unworthy of trust. In other words, physicians do not like being recorded because they assume that the person recording them has negative motivations.

But let’s pause for a moment and look at this a different way. . . what if they don’t have negative motivations? Continue reading ““Doctor, can I record this conversation?””

A Dream About U.S. EMR’s; A Reality in th U.K.

I’m back at it again, talking about my continued love/hate relationship with EMR’s. From my conversations with doctors at different hospitals in our region, it seems that most docs appear to be falling into the “hate” column. Meanwhile, I’m still chugging along with the Allscripts Professional EHR that’s been installed in my office. And while it works just fine for the needs of a 3 physician single-specialty outpatient practice, it’s hardly the type of technology that, by itself, can change medical care for the better for a large number of people.

A recent study challenges that notion. In a study published in Chest, researchers in England sought to determine if inhaled steroids are a risk factor for pneumonia among asthmatics. It has already been shown inhaled corticosteroids are associated with an increased risk of pneumonia among patients with COPD. To determine this they looked at a database of medical information known as The Health Information Network (THIN).

In the UK, EMR’s have been in use for years, and general practitioners are encouraged (but not required) to participate in THIN. When a general practice elects to participate in THIN, software is installed in their EMR which runs in the background. The program collects data, while de-identifying it. The anonymized data is then uploaded to THIN, where approved researchers may have access to it.  There is no cost to the practices for participating, and in return for their participation practices not only receive in depth practice metrics, they also receive a percentage of any research revenue generated from the use of the THIN data. At the time that the study was conducted, the database contained data from 9.1 million patients.

But back to the question at hand. From a cohort of 359,172 people with asthma the researchers were able to identify 6857 people with pneumonia, along with 36,312 control subjects.  They were thus able to find a positive correlation between inhaled steroids and pneumonia. (for more on these findings, see my previous post: ) Continue reading “A Dream About U.S. EMR’s; A Reality in th U.K.”

Why I Stopped Working with Express Scripts

Mail order pharmacies like Express Scripts and Medco have become increasingly prominent players in health care. But these companies are a lot more than simply mail order pharmacies, they are in fact a new generation of pharmacy benefit managers (PBM’s). PBM’s are essentially middle-men between insurance and pharmacy, with companies like Express Scripts merging the dual functions of a PBM and pharmacist into one. PBM’s manage and administer medication benefits for insurance companies. The largest insurance companies contract with them not only to manage the medication benefits of their clients (that would be you), but also to contain costs. Since insurance companies are not in the business of directly managing pharmacy services themselves, they contract with PBM’s to coordinate and manage their patients’ insurance benefits for them. If a PBM can do that at a lower cost, they save (make) money for themselves and the insurance company.

Mail order pharmacies are in a unique position to do this, as they don’t have to maintain brick-and-mortar outlets, and can use the mail to reduce costs . With such an advantage in cost containment, mail order PBM’s are quickly pushing traditional brick and mortar outfits to the periphery (remember Netflix vs. Blockbuster?). Mail order pharmacies are thus becoming giants in this industry. In 2012, Express Scripts completed a $29 billion acquisition of Medco, to create the country’s largest PBM, a publicly traded company with $100 billion in annual revenue. Continue reading “Why I Stopped Working with Express Scripts”

Should EMR’s Be Able To Talk to Each Other?

I’ve written several times before about my love/hate status with my EMR. While I enjoy using mine, I long for it’s usefulness to get to the next level. While the EMR is useful at tracking data, it’s greatest handicap right now, is that it can’t talk to other systems. Data is still locked in individual systems and can’t be shared across platforms. This lack of inter-operability has thus far been the EMR’s greatest handicap, and I have longed for the time when EMRs are able to share data.

But as I see more and more systems being employed in my area and talk with other physicians about their experiences, I am becoming increasingly concerned that  the inexorable march forward is going too quickly.

Shouldn’t we get these systems right before introducing interoperability into the equation?

The administration and the public are now clamoring that the information in these systems should be able to be shared among providers. In effect, that the information should not be “held hostage” by each providers respective system. These are fair and reasonable requests that should be expected in the long run. To that end, some EHR vendors have agreed in principle to begin writing standards that would allow inter-operability between systems.

The unfortunate problem here, and one that the public does not understand, is that these systems are not like the  computer operating systems that they accustomed to using. It’s easy to forget that Microsoft, Word, Windows, Powerpoint, and Macs are more than 20 years old.  They’ve gone through several generations and hundreds of billions of dollars in development by the worlds most talented programmers. All to now finally be at a point where the program does not routinely stop working for some unknown reason. Continue reading “Should EMR’s Be Able To Talk to Each Other?”

The Relationship Between Cystic Fibrosis Exacerbations and Environmental Pollution.

If you don’t know this about me by now, I need to confess something, I’m a bit of a geek. I love  Star Trek (all of em), and I regularly check the NASA website  to see how the Voyager pairs are doing. And yes, of course  I follow the Mars rover’s twitter feed, who wouldn’t?.  So as I was perusing my issue of Chest recently, there was a study that really got my attention. It wasn’t only because of the incredibly important  issue of Cystic Fibrosis and identifying what causes exacerbations. It was the novel way that the authors identified air pollution as a factor that contributed to CF exacerbations.

Air pollution has long been thought to play a role in leading to lung disease. Air pollution is also thought to contribute to exacerbations in people with known lung disease such as asthma, COPD, and Cystic Fibrosis. However, these correlations have been difficult to show,  and have primarily depended upon looking at admission rates for people with exacerbations  of lung disease during periods where there is a known environmental anomaly or excess pollution. Unfortunately such conditions are not very predictable.

A study published in this month’s issue of  Chest showed an intriguing relationship between  air pollution and exacerbations of cystic fibrosis. What was intriguing to me about this study was not only that the authors showed a relationship between CF exacerbations and environmental pollution, but also how they set about demonstrating an association between the two.

They first went back and identified  2204 individual CF exacerbations that occurred at their institution in Belgium. Using the patients’ home addresses, they  calculated concentrations of  particulate matter, ozone, and nitrogen dioxide the patients would have been exposed to around the time of their exacerbations. Continue reading “The Relationship Between Cystic Fibrosis Exacerbations and Environmental Pollution.”

Why Physicians Should Learn to Pronounce Patient Names Properly

I have it on good authority that it’s not easy being green. But I’m willing to wager that it’s a whole lot easier when you have a lovable name like “Kermit”. Imagine being green (or brown) with a name like “Ramachandran”? Growing up with a name like mine certainly had its disadvantages. While most neighborhoods have a local bully who kicks ass and takes names, in my case, he would typically kick ass, but didn’t bother with the name part because he couldn’t pronounce it. Somehow I found that last part more insulting.

 I’ve long since outgrown the sensitivities about my name (although I still make any telemarketer pronounce it properly before talking with them). For most patients and those with whom I only occasionally associate, I go by “Dr. Ram”, which works fine by me. But perhaps those early experiences left me with an impression about how people can be affected in positive ways by getting the pronunciation of their name right, or at least trying to get it right. As well as the negative ways in which people can be affected by getting the pronunciation wrong, or by not even bothering to try.

So I would like to direct a message to those care providers out there with easy to pronounce names, because this  is something that you probably don’t  know. Getting the pronunciation of somebody’s name correctly (or at least trying to) is important. These people often wave you through that initial awkward part of an encounter, simply because they’ve given up hope that people are going to get it right. They tell you it does not matter only because they have already spent too much time in trying to get the name pronounced properly, only to have it reduced to a few letters. They wave away the mispronunciations because they’ve learned to accept that no one is going to invest the few seconds that it will take to pronounce it correctly. But they do care, and make no mistake, it is very important to them. Not taking the time to learn the pronunciation of someone’s name sends a powerful message. It says “We don’t know you, you’re a stranger here” And doing it repeatedly says “I still don’t know you, and I’m too busy to bother to try”. The subconscious message that the patient takes from these encounters is “these people don’t know who I am”. Conversely, taking the time to try to learn the proper pronunciation of a name  says “I’m listening to you” and “I want to know who you are”. Continue reading “Why Physicians Should Learn to Pronounce Patient Names Properly”

Where Medical Reports Go to Die.

It happens thousands of times a day, all across the country. People go to their doctor’s office after some testing has been performed. The physician, unaware that any testing has been ordered by another physician, asks their usual questions. The patient, awaiting an opinion rendered on the recently performed test begins to answer the doctor’s questions with increasing impatience and trepidation, fearing the worst. “Why is he asking so many questions. . . why is he not telling me the results? Did my cholesterol panel show cancer?” And finally the question comes to the fore;

“ Doctor did you get my test results?”

“No, what test did you have”

“But I told them to send it to you!!” Continue reading “Where Medical Reports Go to Die.”

Snow Birds and The Unfulfilled Promise of Electronic Health Records.

Please enjoy this recycled oldie-but-goodie while I spend the next 6 weeks juggling a high case load with studying for the boards with taking care of two babies, etc. . .

The migration has begun. All over Michigan, the annual migration of flocks moving south is in full swing. And behind those flocks, the other annual Michigan migration is starting too. Our office is starting to see our winter ‘checkout’ patients before they migrate south for the winter.

Over the next month, I’ll see a multitude of patients come in to get ‘checked out’ and get paper prescriptions to take with them to Florida in case they find themselves under threat of missing a golf outing due to varying states of cougheyness and/or wheeziness. Many of them have physicians in Florida that they sometimes see, and occasionally they get hospitalized while down there. They usually come back with an impeccable tan, an extra spring in their step, and a story of their various physician visits and /or hospitalizations with more holes in it than your average disability application.  They also explain that any tests that I’m about to order have probably already been done by their physicians in Florida, and they’d like me to take a look at those records before I order anything. We then start the dance of trying to get copies of their charts, which goes something like this:

Records Requested:                                 Records Received:
Request for chart.                                                     Nothing                  

Second request.                                                       Nurses notes 

Third request..                                   Copy of diet recommendations.

This whole dance has started to make me wonder about my ardent support for the electronification of medical records, which is supposed to do for medical care what the invention of sliced bread did for a fledgling sliced deli meat industry. By now we’re all aware that the Institute of Medicine (which by the way, to me sounds like a made up name) tells us that a gazillion patients are unnecessarily being decapitated every day because physicians’ illegible orders for ‘allow decaf for patient’ are being misinterpreted by hapless nurses as ‘and now decapitation’. Electronic medical records, says the Institute, would successfully ameliorate the silent killer that is physician penmanship.
But how does this impact the care of patients who had treatment from another physician or medical system, whether it was across the country or across the street? Nada. If I want to see those high tech electronic records, it still requires that I talk to a person, those records must then be printed, then faxed. Because of this, many of these tests end up being duplicated, and because of the awesomeness/stupidness of medicare, it has continued to pay for the duplication of these tests even if it has only been days since the original tests were done.

It seems to me then, that adding electronic medical records to the current system is kinda like adding a microchip to an abacus. . . in the end all you get might be nothing more than a fantastically expensive Goldberg machine. To me the only way that electronification of medical records will ever be the revolution that it’s backers claim it will be, is when there is a high degree of compatibility between systems. This would allow patients’ data to be shared among multiple different records systems. It would provide patients greater mobility between medical systems, rather than being tied to whatever system their PCP happens to be in. That greater mobility in turn might place greater pricing pressure on different medical systems as they are forced to compete to a greater degree. So how exactly do we implement this? I don’t know. But I promise I’ll start thinking about it once I’m done faxing all these diet recommendations to Florida.


The migration has begun. All over Michigan, the annual migration of flocks moving south is in full swing. And behind those flocks, the other annual Michigan migration is starting too. Our office is starting to see our winter ‘checkout’ patients before they migrate south for the winter. Continue reading “Snowbirds”